Archive for the 'Musculoskeletal Disorders' Category

A Simple Way to Make a Major Difference in your Health

Vitamin D supplementsA recent study from the Intermountain Medical Center Heart Institute in Murray, Utah has found that people who increase their vitamin D blood levels to 43 or higher may lower their risk of diabetes, heart attack, heart failure, high blood pressure and heart disease.

Heralded as “One of the Top 10 Medical Breakthroughs of 2007″, Vitamin D continues to surface in new research as a critical nutrient in maintaining good health and preventing disease, yet almost half of the world’s population has lower than optimal levels of vitamin D.  

It is well known that hip fractures and muscle weakness, in people over 50, are linked with a deficiency in Vitamin D.  Many recent studies have also found that low Vitamin D levels are associated with a number of serious, chronic diseases, such as diabetes, gum disease, multiple sclerosis and other autoimmune diseases, peripheral neuropathy, osteoporosis, cancer, stroke, mental decline, depression, high blood pressure and heart disease.

A Vitamin D deficiency can be treated with a simple daily supplement and a blood test can measure the circulating Vitamin D levels in your blood.  A level of 30 nanograms per milliliter of vitamin D is considered normal, although this may vary from lab to lab.

Many doctors are routinely drawing blood levels of Vitamin D to to make sure patients are getting enough vitamin D to optimize good bone health and prevent chronic disease. Ask your doctor about this.

Important Note: Vitamin D is a fat soluble vitamin, thus toxicity can occur from high intakes of vitamin D. Overdosage can occur from large amounts of supplements or cod liver oil, but it is unlikely to result from sun exposure or diet. Parents should consult with their pediatrician before giving any child vitamin D supplements. Excess vitamin D can reach toxic levels and be harmful.

  Source: “Boosting Vitamin D Can Do a Heart Good”, HealthDay News, March 15, 2010 


Generics Versus Brand Names

The FDA allows a variance of 20% when it comes to generic medicationsBrand named drugs are becoming more and more expensive these days and many people just can’t afford them.  Often insurance companies won’t pay for a brand name if a generic equivalent is available, so more than ever people are faced with the question–are the generics equally effective and safe?

Both the FDA and generic drugmakers say that the generics are clinically identical to the brand named medications, but is this always the case?

Generic drugs have to meet the requirements of the FDA which requires ”90% confidence intervals for maximal concentration and the area under the concentration-time curve must be no less than 80% and no more than 125% of the means for the branded drug”, according to MedPage Today.  In other words, yes there can be some variation. 

This variation may or may not be a problem.  It can be serious if the disease requires very specific blood levels of the drug, however, such as in a seizure disorder.  

Carbamazepine (Tegretol) is a drug used to treat seizure disorders.  The levels of the drug need to be predictable, reliable and effective, otherwise a seizure may occur.  In a recent study at John Hopkins University, generic versions varied markedly in FDA-sanctioned bioequivalence studies.  So in the case of carbamazepine, this variability could have significant clinical consequences for patients who switch from the branded product or from one generic version to another.

Another drug of concern is generic thyroid.   Fortunately a blood test (TSH) can determine if you’re getting the right amount of thyroid medication, but it should only be done two months after taking the medication on a daily basis. Also, the problem might arise if the pharmacy switches generic brands, which they have been known to do.  So if you have a choice, choose the brand name when it comes to thyroid medicine. If you’re forced to take the generic option, let your doctor know and pay attention to the color and appearance of the pill.  If it ever changes, ask the pharmacist.  If the pharmacy does switch generics, let your doctor know so a blood test can be scheduled. 

 As a health care practitioner, I’m concerned about generic alendronate (Fosamax).  While the generic version may contain the correct amount of the drug, you may not be getting the absorption needed for it to be effective.  This is particularly important for medications that have poor GI absorption to begin with. The absorption of the generic may be even worse than the brand name with the end result being little or no benefit when it comes to improving bone density. 

Venlafaxine (Effexor), a popular drug for depression was recently studied by Franck Chenu, PharmD, PhD, of the University of Ottawa.  The researchers found that the side effects of the generic version was three times more common than with the branded version, Effexor. Their findings were reported in the July 2009 issue of the Journal of Clinical Psychiatry.

When it comes to generics it’s always a good idea to talk it over with your doctor before you make the decision of generic versus brand name.  And if you can only afford generic, let your doctor know. 

Source: “AAN: Wide Variability in Generic Versions of Epilepsy Drug”, MedPage Today, May 1, 2009
Source: “Generics versus Brands: Are They Really Equivalent?”, MedPage Today, August 25, 2009

Dizziness Linked with Poor Bone Health

A woman with osteoporosisLow bone mineral density may be associated with a disorder that causes dizziness, according to Korean researchers.  Benign positional vertigo is an inner ear disorder that results in the sudden onset of dizziness, spinning, or vertigo when moving the head.  In this recent study, people with osteopenia had double the risk of benign positional vertigo, and those with osteoporosis had triple the risk of the condition, which was unrelated to head trauma or other known causes.

Osteoporosis is a major public health threat for 44 million Americans and is known as the “silent disease”. It is a silent disease in that it progresses insidiously and painlessly up until the first symptom, which is usually a broken bone.  Unfortunately by then, most of the damage has been done.  Early detection and prevention of osteoporosis is vital. (Image courtesy of Merck

Both men and women over age 50 are at risk. One-half of all women and one-fourth of all men over age 50 will have an osteoporosis-related fracture in their remaining lifetime. This occurs despite the fact that osteoporosis can be prevented and treated.  

Read more about the prevention, detection, and treatment of Osteoporosis

Source: Jeong S-H, et al “Osteopenia and osteoporosis in idiopathic benign positional vertigo” Neurology 2009; 72: 1069-1076.

Source: “Dizziness Linked to Bone Health” MedPage Today, March 23, 2009


Higher Calcium Intake Linked with Lower Cancer Risk

Milk is an excellent source of calciumHigher calcium intake may reduce the risk of digestive system cancers in both men and women according to a study of men and women over 50 from the National Institute of Health.  The study also found a reduction in total cancer risk with increasing calcium intake in women, but not men. The analysis showed no effect of calcium intake on the risk of breast cancer or prostate cancer, however.

The highest calcium intake, and lowest cancer risk, in this study was consistent with current recommendations of 1,200 mg/d for adults over 50.  Calcium supplements were taken by 14% of the men and 41% of the women in this study. 

Calcium is also well known as an essential nutrient in the battle against osteoporosis, which is known as the “silent disease”.   It is a silent disease in that it progresses insidiously and painlessly up until the first symptom, which is usually a broken bone.  Unfortunately by then, most of the damage has been done.  Both men and women over age 50 are at risk of osteoporosis.  One-half of all women and one-fourth of all men over age 50 will have an osteoporosis-related fracture in their remaining lifetime.

To prevent osteoporosis, the current guidelines for adults over 50 are to consume 1,200 mg/d of calcium in the form of food or calcium supplements.  Adults under age 50 need 1,000 mg daily, and teenagers need the most, 1300 mg/d.

Calcium in foods, especially from milk and milk products, has been found to be better absorbed than from supplements.  Milk products include hard cheese, cottage cheese, yogurt, green vegetables and spinach.  A simple way to estimate one’s daily intake of dietary calcium is to multiply the number of dairy servings consumed each day by 300 mg.   One serving equals 8 oz of milk or yogurt, 1 oz of hard cheese, 16 oz of cottage cheese, or 2 cups of broccoli.

Despite all efforts to eat a calcium-rich diet, if dietary intake of calcium remains below the recommended value, calcium supplementation is recommended. 

Read more important details about Calcium supplementation and Osteoporosis from Bay Area Medical Information.

Source: Park Y, et al “Dairy food, calcium, and risk of cancer in the NIH-AARP Diet and Health Study” Arch Intern Med 2009; 169: 391-401.
Source: MedPage Today, February 23, 2009

The Hope and Hype of Glucosamine and Chondroitin

About the dietary supplements

Bones and muscles of the kneeGAIT is the first large-scale study in the United States to test the effects of the dietary supplements glucosamine and chondroitin sulfate for the treatment of knee osteoarthritis. This clinical trial tested whether glucosamine and chondroitin, used separately or in combination, reduced pain in people with knee osteoarthritis.

Glucosamine and chondroitin sulfate are substances found naturally in the body. Glucosamine is believed to play a role in cartilage formation and repair, while Chondroitin Sulfate is thought to give cartilage its elasticity. Both supplements also have some anti-inflammatory effects that may account for the pain relief.

Both glucosamine and chondroitin sulfate are sold over-the-counter as dietary or nutritional supplements. They are extracted from animal tissue: glucosamine from crab, lobster or shrimp shells; and chondroitin sulfate from animal cartilage, such as tracheas or shark cartilage.

The benefit

In the GAIT study, participants who took glucosamine and chondroitin and had moderate-to-severe pain, experienced significant pain relief–about 79 percent had a 20 percent or greater reduction in pain versus about 54 percent for placebo.  However, the participants in the mild pain subset who took glucosamine and chondroitin sulfate, did not experience statistically significant pain relief.  These findings are consistent with the results physicians report in their actual office practice where some people get pain relief, and some don’t.

While it has been speculated that glucosamine supplements may be able to help the body repair damaged cartilage, this has yet to be proven, and in the GAIT study there was in fact no slowing of loss of cartilage in patients who took glucosamine and chondroitin, together or alone.  This was determined after assessing the x-ray data on  581 knees of participants in this study.  More research needs to be done, but at this point, there appears to be no benefit from taking these dietary supplements, other than for pain relief in those experiencing moderate-to-severe pain.

How to take glucosamine and chondroitin

Because dietary supplements are unregulated, the quality and content of products on the store shelves may vary widely. Identical products of glucosamine and chondroitin used in the GAIT study may not be commercially available.  A well-respected private laboratory, Consumer performs independent tests on dietary supplements  which it publishes online.  However, these results are only available for an annual subscription fee.  The National Arthritis Foundation recommends simply choosing only products sold by large, well-established companies. 

If you decide to take these supplements:

  • Always consult your doctor before deciding to try these supplements, and make sure that osteoarthritis is the cause of your pain.
  • Consult your doctor about the proper dosage. The amount used in studies of glucosamine was 1,500 mg per day and in studies of chondroitin sulfate, 1,200 mg per day was used. Divide the daily total into three doses per day.
  • You can try the supplements along with your current medications for three months. If you don’t experience any difference in your symptoms within this time, you probably will not get any relief from using the supplements. If the supplements are having a beneficial effect, continue on the supplement, but it may be possible to reduce the dose after the first few months:
    • First two months: 1500 mg glucosamine and 1,200 mg chondroitin per day in three divided doses 
    • Next month: try reducing the dose to 1,000 mg of glucosamine and 800 mg of chondroitin, in two divided doses. 
    • Next month: try reducing to 500 mg glucosamine and 400 mg of chondroitin in one dose
    • If symptoms return,  increase to the full dosage.
  • Do not stop or reduce your current prescribed medications without talking with your doctor.
  • Choose products sold by large, well-established companies that can be held accountable.
  • Read the product labels carefully to make sure the ingredient lists make sense to you. If you have trouble, ask your pharmacists for help.
  • Recommended doses should cost about $1 to $3 per day, but most insurance companies do not cover this cost.

Side Effects

Both glucosamine and chondroitin sulfate have been used in Europe for several years, with few reported side effects and in most human studies, glucosamine sulfate has been well tolerated for 30 to 90 days. But these supplements are not appropriate for all forms of arthritis or for all people.

Pregnant women should not take this or anything else without asking their obstetrician.  Diabetics should be especially cautious–It remains unclear if glucosamine alters blood sugar levels. Since glucosamine can be made from the shells of shrimp, crab, and other shellfish, people with shellfish allergy or iodine hypersensitivity may theoretically have an allergic reaction to glucosamine products.  There are reported cases suggesting a link between glucosamine/chondroitin products and asthma exacerbations.  In theory glucosamine may increase the risk of bleeding. Caution is advised in patients with bleeding disorders or taking drugs that may increase the risk of bleeding.

Side effects may include upset stomach, drowsiness, insomnia, headache, skin reactions, sun sensitivity, and nail toughening. There are rare reports of abdominal pain, loss of appetite, vomiting, nausea, flatulence (gas), constipation, heartburn, and diarrhea.

Image of the knee courtesy of the National Institute of Musculoskeletal and Skin Diseases

via “Questions and Answers: NIH Glucosamine/chondroitin Arthritis Intervention Trial Primary Study (GAIT)”, (The University of Utah, School of Medicine coordinated this study, which was conducted at 16 rheumatology research centers across the United States.) National Center for Complementary and Alternative Medicine (NCCAM), January 09, 2009

via “Glucosamine and Chondroitin Sulfate”, Arthritis Foundation

via “Glucosamine and Chondroitin Sulfate“, American Academy of Orthopedic Surgeons


Restless legs syndrome improved with compression devices

Compression deviceCompression devices on both lower legs, used an hour per day, completely relieved the symptoms of Restless Legs in a third of Restless legs Syndrome patients during a recent study from Walter Reed Army Medical Center. 

Compression devices have long been used to improve blood flow in the legs in order to improve edema and also prevent the development of deep vein thrombosis (blood clot in a vein) in high risk patients.  

Using a compression device regularly may be impractical for some because it does require an hour of immobility per day, but most patients have symptoms in the evening when they are relaxing anyway, and this would be an ideal time to use the device. 

via “Compression Devices Ease Restless Legs Symptoms” MedPage Today, January 14, 2009
via  “Pneumatic Compression Devices Are an Effective Therapy for Restless Legs Syndrome”
 Chest, January 2009

Fosamax and Boniva linked to dental complications

Drawing of a toothOsteonecrosis of the jaw, as a complication of dental procedures, has occurred in 4% of patients taking oral alendronate (Fosamax), whereas none of those who didn’t take the drug experienced any complications.

Fosamax, as well as Boniva and Actonel, are oral bisphosphonates.   Fosamax is the most widely prescribed oral bisphosphonate, and in 2006 it was the 21st most prescribed drug overall. 

In an article in MedPage Today, the the researchers are quoted as saying, “…if patients are using bisphosphonates, dentists should consider alternate treatment options for non-necessary extractions and good oral hygiene should be achieved before extractions to minimize microbial load. Also, follow-up should be more vigilant and a chlorhexidine rinse pre- and post-operatively ‘can be effective’ in ensuring socket and wound healing and mucosal coverage of exposed bone…”

These findings are preliminary, but if you’re taking any one of the bisphosphonates, be sure to let your dentist know, especially before any dental procedures.

via MedPage Today, January 2009

The benefits of dairy products in childhood

MilkYoung children who have two or more servings of dairy products a day throughout childhood have significantly better bone health as teenagers, according to researchers from the Boston University School of Medicine.  And, if a nondairy protein is added to this diet, their bone health is even more improved.   

via Moore LL, et al “Effects of Average Childhood Dairy Intake on Adolescent Bone Health” J Pediatr 2008: DOI: 10.1016/j/jpeds.2008.05.016.

The down-side of antibiotics

The FDA announced yesterday the requirement of a new boxed warning about the risks of tendinitis and tendon rupture on the labels of fluoroquinolone antibiotics. Drugs in this class are relatively new and are commonly prescribed for certain bacterial infections.  They include:  ciprofloxacin (Cipro, Cipro XR, and Proquin XR), gemifloxacin (Factive), levofloxacin (Levaquin), moxifloxacin (Avelox), norfloxacin (Noroxin), and ofloxacin (Floxin), as well as generic versions. Those at highest risk of this complication include persons older than 60, and recipients of a kidney, heart, or lung transplant, as well as corticosteroid users.  The achilles tendon (in the ankle) is the most common site of tendon rupture.

According to the FDA, “Physicians should advise patients, at the first sign of tendon pain, swelling, or inflammation, to stop taking the fluoroquinolone, to avoid exercise and use of the affected area, and to promptly contact their doctor about changing to a non-fluoroquinolone antimicrobial drug.” Although these side effects are uncommon, they certainly can be serious and would not be expected in someone taking the drug who is uninformed.  

Antibiotics are powerful, yet often misused drugs.  They have saved millions of lives and have dramatically improved the quality of health care in this country and around the world, yet today these drugs have also become a growing source of serious side effects as well as a cause of many drug-resistant bacterial infections.  The U.S. Centers for Disease Control (CDC) has declared antibiotic resistance one of its “top concerns.? 

Antibiotics should never be taken for a viral infection, such as a cold or the flu, because they will not make a difference, other than possibly causing undesirable side effects.  Antibiotics should only be taken as directed and under the supervision of a health care provider.

via FDA, July 8, 2008

The Best Type of Exercise that Generates the Least Force on the Knee

Biking is the best exercise for those who have knee problems or have had a total knee replacementBiking is the exercise that produces the least impact on the knee, and hence the best lifetime exercise for those who have undergone a total knee replacement, according to orthopedic researchers from Scripps Clinic in La Jolla, Calif. 

Biking is also a good exercise for strenthening the muscles that support the knee. 

Specifically, the findings from their study revealed the following impact on the knee:

  • Biking = 1.3 times the person’s body weight.
  • Treadmill = 2.05 times the body weight.
  • Walking on level ground = 2.6 times the body weight.
  • Tennis = 3.1 to 3.8 times the body weight, with serving producing the highest impact. Doubles tennis, instead of singles is often recommended to patients who have undergone total knee replacement (TKR), as it is less stressful to the knee.
  • Golf swings = 4.5 times body weight on the forward knee and 3.2 times body weight in the opposite knee. The researchers noted however that the impact from a golf swing occurred in an instant, while the forces produced by jogging are constant, which is worse. Golfers, who have previously undergone TKR, might want to consider consulting with a pro to modify the swing so that less force is exerted on the knee.
  • Jogging = 4.3 times body weight. Because of this repeated impact on the knee, it is advisable for people who’ve undergone knee replacement to give up jogging altogether and switch to another form of exercise.

SOURCE: American Academy of Orthopaedic Surgeon’s annual meeting April 2008